How to break the enigma of the

OPAT code

Debbie Cumming

How to break the enigma of the OPAT code!

Debbie Cumming

OPAT works…..

• in delivering good clinical outcomes…• whilst releasing bed days

BUT……must not forget the need for cost effectiveness:• See: Chapman et al JAC 64: 1316-1324 (2009)

So what am I going to talk about:

• Current NHS challenges

• Data capture and coding

• How to think about costing for your OPAT service

• Can we break the enigma of the OPAT code?

Current challenges?

• Hospitals trying to close beds• Emphasis on treating patients in community (McKinsey report and e.g. Start Smart then Focus)• So more emphasis on OPAT

Until now……From now on……

• Need to move to sustainable & correctly funded

But currently, no nationally recognised coding or data capture mechanism

for specifically funding OPAT

Remember you only get paid for what’s been coded:

Healthcare Resource Groups (HRG)

Cellulitis

Diabetic Foot Ulcer

Prosthetic Joint Infection

Resistant UTI

… Hospital Coders use HRG codes

Remember you only get paid for what’s been coded:

HRG Tariff

Cellulitis £795

Diabetic Foot Ulcer

£2,651

Prosthetic Joint Infection

£2,787

Resistant UTI £1,502

… Each HRG carries a specific tariff

Remember you only get paid for what’s been coded:

HRG Tariff DurationTrim Point

XS Bed Day Fee

Cellulitis £795 5 days £180

Diabetic Foot Ulcer

£2,651 27 days £200

Prosthetic Joint Infection

£2,787 18 days £232

Resistant UTI £1,502 12 days £214

If your patient stays longer than the trim point

then the hospital receives an XS bed day fee

for every extra day – but NB it’s not profit making!

Knowing a bit more about coding, can you optimise your

OPAT income?

• Short term patient =

£OPAT HRG + £new hospital HRG

• Long term patient =

(£OPAT HRG + XS day payment) + £new hospital HRGsss

It is all in the coding….

We’ve introduced coding.. Now let’s talk about data capture….

• How is OPAT activity captured? ….. Otherwise you still won’t get paid….!

• What are the recognised pathways that OPAT patients might travel to capture the activity? ….

• What are the various pros and cons for each pathway?

Patient: Admit… Discharge …then OPAT

Pros:

•New patient into bed ... so new HRG gained by Trust

•Length of stay (LOS) figures … appear low

Cons:

•No payment for OPAT (H@H)

•No XS bed day fee (past trim point)

•Readmission figures compromised if patient bounces back in

Patient: Admit … Home Leave for OPAT

Pros:

•An established NHS method for data collection – Coders are happy!

•HRG reflects the Consultant episode past the Trim point

•LOS a true reflection

Cons:

•The bed needs to remain open … so no new HRG payment

Patient: Admit … Day Attender for OPAT

Pros:

• LOS kept short

Cons:

• Clinical governance reduced as not under 24/7 OPAT care

• Not charged for 24/7 cover given by OPAT team

• Only for actual iv administration

Patient: Admit … Virtual Ward for OPAT

Pros:

• LOS can be calculated

• Appropriate clinical governance achieved

• Readmission not compromised

• Allows money to follow patient including XS bed day fees (£?????K)

Cons:

• Coders unhappy because data dictionary does not allow virtual wards

• Skews figures … more patients than beds

Patient: Admit …Transfer to Local Tariff

for OPAT (4.6 code)

Pros:

• Accepted data capture system

• Maximum income for Providers – HRG and Local Tariff

Cons:

• Could be expensive for the Commissioners

St Elsewhere Patients

• Don’t forget you need to charge St. Elsewhere ….(or lose £???)

• As They will be getting the HRG (and XS bed day fee if patient not technically discharged) …

• And You are going to deliver their intravenous antibiotics… ... for free!!!

So what do you think?

• Will the NHS data capture systems evolve with us?

• … And are the coders on our side?

• To allow a sustainable and financially viable OPAT service ... to reach its full potential.

How to cost your own OPAT service:

How do you cost OPAT?1. Start working out the individual activities that go into making a successful OPAT outcome …

2. Allocate a time for each

3. Allocate how many times during the OPAT episode that happens

Let’s begin with a few examples…. Cost:

££

££

a) Risk Assessment

b) Insertion of Mid lines

How do you cost OPAT?• And then continue: Cost:

££

££

££

££

££

c) Consumables

d) Average 20 day OPAT duration,

e) 10 visits by District Nurses, 10 by IV Nurse Specialist

f) Travel time and costs

How do you cost OPAT?• And then continue:

Cost: ££

££

££

££

££

££

££

££

££

££

££

££

f) Virtual Ward Rounds, g) Appointments, h) Audits etc…

How do you cost OPAT?• Till you have your complete list!

Cost: ££

££

££

££

££

££

££

££

££

££

££

££

££££££

Total Cost

Per Day Cost

But there is more:

• Think from a different angle….

• Let’s think about staffing for the whole year….

• Who do you need to pay to deliver your service?

• What are your capacity brackets? 1000, 1500, 2000, 10,000….

• How many bed days can you manage with that many staff? How many bed days released per year?

The costs just discussed relate to delivering

the iv OPAT treatment but also need to work out your

costing for the staff needed:

Staff needed

Patient mixIndicative daily tariff

Number of OPAT bed daysExpected income

So: OPAT does work … but• You need to understand about coding and data capture

• You mustn’t presume that you are getting paid - correctly

• You do need to be aware of how much your hospital’s OPAT service costs….

• So that you can be cost effective within….whatever capacity bracket(s) you want to work

• So that you can deliver a sustainable service

Last but one slide!

What is your preferred option …

… to adopt nationally for OPAT?

…. Virtual Ward? … Local Tariff?

…..National Tariff (excluding ….?)

Will we solve the enigma of the OPAT code?

Questions to ponder?

• Do you pay your district nurses?• Who pays for the antibiotics?• Do you charge for St Elsewhere patients?• What pathway do you follow? Virtual ward, day attender, local tariff, … or

other?• Do you have capacity brackets built into your model?• Does the money follow the patient?• Do you have any problems with finance?• Yet they want more and more:

Acute Care in the Community…..• What about ambulatory care models … ?

The future is challenging but remember OPAT is a solution not a problem